Broker or Market Maker Transaction Inquiry and Challenge

I would appreciate your assistance in resolving the problem(s) herein identified with the following transaction at your earliest convenience.

Brokerage/M. Maker's Name:

Brokerage/M. Maker's Address:

Broker/M. Maker Transaction #

Date of Filing:

Our Transaction File #

Customer Name:

Customer Address:

Customer Telephone:

Customer E-Mail Address

Customer Account #:

Date & Time of Transaction:

Description of Transaction:

Description of what went wrong:

Estimate of how much money lost:

Date, Time, & Name of Prior Contact(s):

Result of Prior Contact(s):

I would appreciate your answering the following questions or forwarding me the following data or information regarding this transaction at your earliest convenience:

This inquiry and challenge to the broker transaction identified herein is being filed pursant to SEC, NASD, and State Securities guidelines. A response is requested within 30 days.

Please be advised that an unsatisfactory resolution of this inquiry and challenge may be followed by a formal complaint to the SEC, NASD Regulation, State Securities Regulators, and other applicable Securities Exchange authorities.

Thank you for your consideration and assistance in this matter



___________________________________
Signature


___________________________________
Date